We assessed the risk of clinically significant drug interactions in patients receiving antiretrovirals, and their recognition by physicians. Clinically significant drug interactions were recorded in 27% of 159 patients, with 15% of interactions potentially lowering antiretroviral concentrations. Risk of clinically significant drug interactions was significantly related to receipt of protease inhibitors. Only 36% of clinically significant drug interactions were correctly identified by physicians.

Intracellular accumulation of the protease inhibitors (PIs) saquinavir (SQV), ritonavir (RTV), and indinavir (IDV) was determined in 50 human immunodeficiency virus-positive patients. Following extraction, PIs were quantified by mass spectrometry. Paired plasma and intracellular samples were collected over a full dosing interval from patients (13 on SQV, 6 on RTV, 8 on IDV, 16 on SQV plus RTV, 7 on IDV plus RTV) with a plasma viral load of <400 copies/ml. Data were expressed as intracellular/plasma drug concentration ratios. A hierarchy of intracellular accumulation was demonstrated by the following medians: 9.45 for SQV > 1.00 for RTV > 0.51 for IDV. Coadministration of RTV did not boost ratios of SQV or IDV within the cell or in plasma, although absolute plasma and intracellular SQV concentrations were increased by RTV. Seven individuals receiving SQV in hard-gel capsule form (median, 32 months) had higher intracellular/plasma drug ratios than all other patients receiving SQV (median, 17.62 versus 4.83; P ‫؍‬ 0.04), despite consistently low plasma SQV concentrations. How this occurs may provide insight into the mechanisms that limit adequate drug penetration into sanctuary sites.The failure to achieve and maintain suppression of human immunodeficiency virus (HIV) replication is emerging as a major problem in antiretroviral therapy (ART). One large cohort study has recently reported a mean time before virological failure on first-ART-regimen drugs of 12 months but with markedly decreasing durability for each successive regimen (F. Palella, J. Chmiel, M. Deloria-Knoll, A. Moorman, S. Holmberg, and the HIV Outpatient Investigators, 8th Conf. Retrovir. Opportunistic Infect., abstr. 268B, 2001). Treatment failure is multifactorial and includes viral resistance, poor adherence, and pharmacological and host factors. Much interest has been generated by potential pharmacological mechanisms of failure. HIV replicates within cells; therefore, drugs must penetrate intracellularly at concentrations sufficient to inhibit viral replication. Failure to do so results in the establishment of a sanctuary site where virus may evolve in the absence of selection pressure from the drug (22) or where subtherapeutic levels generate drug-resistant virus with subsequent "seeding" into plasma. Virus from sanctuary sites, such as the central nervous system and seminal fluid, can exhibit genotypic resistance profiles, which differ from peripheral blood isolates (6, 21). Pharmacological studies that examine the cellular and tissue penetration of HIV drugs are crucial to the understanding of sanctuary sites and the subsequent evolution of drug resistance and the failure of ART. This understanding may inform the design of strategies to maximize drug potency. In particular, the roles of cellular efflux transporters such as the P-glycoprotein (P-gp) in limiting the intracellular penetration of drugs and the potential for ritonavir (RTV) to boost intracellular drug accumulation within sanctuary sites deserve further investigation.We have previou...

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Students of Javanese society have long recognized that the Java War (1825–30), the bitter five-year struggle against European colonial rule in Java, constituted a watershed in the history of modern Indonesia. In his recent textbook, Professor Ricklefs has characterized the year 1830 as ‘the beginning of the truly colonial period in Java’, arguing that the Java War marked the transition point between the ‘trading’ era of the Dutch East India Company (VOC) and the years of ‘colonial’ exploitation ushered in by Johannes van den Bosch's well known ‘cultivation systems’. In military and political terms, the costly Dutch victory over the javanese made them, for the first time in their three and a half centuries of involvement in the archipelago, the undisputed masters of Java. At the same time, scholars of Javanese Islam have suggested that the defeat of the Javanese leader, Dipanagara (1785–1855), and the religious ideals for which he fought (most notably his goal of strengthening the institutional position of Islam in Javanese society), temporarily undermined the morale and self-confidence of the Islamic communities in Java. Specialists in the history of the central Javanese principalities (vorstenlanden), especially those interested in cultural developments, have also seen the Javanese failure in 1825–30 as a setback to the vitality and independence of the Javanese cultural tradition, a time when Javanese society began to turn in on itself and lose something of its strength and flexibility.

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Evidence of Epstein-Barr virus (EBV) shedding in the saliva and tear film has been sought to explain the pathogenesis of the oral and ocular features of Sjogren's syndrome. Patients with human immunodeficiency virus (HIV) infection are purported to have a higher incidence of keratoconjunctivitis sicca. Twenty patients with definite Sjogren's syndrome (primary and secondary), 19 with HIV infection, and 15 normal controls were recruited and studied. Human herpes viruses (EBV 1 and 2, CMV, HZV, and HSV-1) in tear film were detected by polymerase chain reaction of DNA extracted from Schirmer strips. HSV-1, VZV, and CMV were not detected in any tear samples. EBV-1 DNA was found in the tear film of 4 patients with Sjogren's syndrome, which was not significantly different from the control group (P = 0.18). Twelve patients with HIV infection had evidence of EBV-1 in their tears, which was significantly different from controls (P = 0.0002) and patients with Sjogren's syndrome (P = 0.014). EBV-2 was found in 3 patients with HIV and in 1 patient with secondary Sjogren's syndrome, and was always found as a co-infection with EBV-1 (P = 0.01). This represents the first report examining EBV types 1 and 2 in the tear film and also EBV in the tear film of patients with HIV. Shedding of EBV in the tear film was not related to the presence of keratoconjunctivitis sicca in Sjogren's syndrome. EBV-2 co-infection with EBV-1 has not been previously reported in the tear film. EBV infection is abnormally regulated in Sjogren's syndrome and HIV, and it is likely that the presence of EBV in the tear film is related to the patients' altered immune status.

SummaryA 19-year-old man presented with community-acquired pneumonia, complicated by pneumomediastinum. Subsequently he was found to be HIV-positive, and to have Pneumocystis carinni pneumonia.